Don Smith remembers the moment he awoke in an intensive care unit after 13 days in a medically induced coma. His wife and daughter were at his bedside, and he thought it had been only a day since he arrived at the emergency room with foot pain.
Smith said his wife 鈥渟lowly started filling me in鈥 on the surgery, the coma, the ventilator. The throbbing in his foot had been a signal of a raging problem.
鈥淲hen you hear someone say a person died of infection, that鈥檚 sepsis,鈥 said Smith, 66, of Colorado Springs, Colorado, who went to the ER shortly before Christmas 2017. Ultimately, he spent almost two months in the hospital and a rehab center following multiple surgeries to clear the infected tissue and, later, to remove seven toes.
Sepsis, the body鈥檚 extreme response to an infection, affects in the United States annually. It stems from fungal, viral, or bacterial infections, similar to what struck Madonna this year, although the singer never said whether she was diagnosed with sepsis. Treatment delays of even a few hours can undermine a patient鈥檚 chance of survival. Yet sepsis can be difficult to diagnose because some patients don鈥檛 present with common symptoms like .
A , finalized in August, ups the ante for hospitals, setting specific treatment metrics that must be met for all patients with suspected sepsis, which could help save some of the 350,000 adults who die of infections annually. Children, too, are affected, with some estimates that 75,000 are treated each year for sepsis and . Hospitals that fail to meet the requirements risk losing potentially millions in Medicare reimbursement for the year.
Still, because the rule applies broadly, it has triggered pushback for its lack of flexibility.
Efforts to reduce sepsis deaths are welcome, but 鈥渨here it gets controversial becomes 鈥業s this the best way to do it?鈥欌 said , an infectious disease physician and associate professor of population medicine at Harvard Medical School.
The approach requires that blood tests be done quickly to look for markers that may indicate sepsis. Also, the measures say antibiotics must be started within three hours of identifying a possible case. The quality measures, called the Severe Sepsis/Septic Shock Early Management Bundle, also call for certain other tests and intravenous fluids to keep blood pressure from dropping dangerously low.
In , which was issued in May, Medicare regulators wrote that the treatments have resulted in 鈥渟ignificant reductions in hospital length of stay, re-admission rates and mortality,鈥 since the guidelines were initiated in 2015 under a requirement that hospitals simply report whether they were following them or not.
鈥淭hese are core things that everyone should do every time they see a septic patient,鈥 said , a critical-care physician, a professor of medicine at the University of Kansas, and the chairman of the Sepsis Alliance, an advocacy group backed by individual, government, and health industry funding.
The final rule builds on that earlier effort. Nationwide, an average of 57% of patients received care that met the guidelines in 2021, with the most compliant averaging 80%, according to the Biden administration.
But, starting in fall 2024, hospitals must move beyond simply reporting on the measures and meet the specific treatment benchmarks, which will be added to Medicare鈥檚 Hospital Value-Based Purchasing Program.
鈥淏efore, even if you were reporting 0% compliance, you didn鈥檛 lose your money. Now you actually have to do it,鈥 said Simpson.
Failing to meet those measures and other patient-safety standards could be costly: Smaller hospitals could lose 鈥渉undreds of thousands鈥 of dollars in Medicare reimbursements annually; for large institutions, 鈥渋t鈥檚 in the millions-of-dollars range,鈥 said Akin Demehin, senior director of quality and patient safety policy at the American Hospital Association.
The hospital association opposed the final rule, to the Centers for Medicare & Medicaid Services that the recommended treatments had not kept up with evolving science and that their focus on quick antibiotic administration for all suspected cases 鈥渉as the high potential to lead to excessive use.鈥 That could fuel antibiotic resistance.
Similar concerns have been cited by other professional medical associations, including the Infectious Diseases Society of America. In , it called for modifying the metrics to target only patients with septic shock, the most serious form of the condition, rather than all suspected sepsis cases. The society also argued that physicians need more flexibility.
What鈥檚 more, there is debate over whether broadly implementing the treatment regimen will save lives.
Rhee in JAMA. In an opinion piece he co-authored, Rhee cited four studies, , showing broad-spectrum antibiotic use increased after the sepsis bundle was introduced eight years ago, yet there was little or no change in outcomes for patients.
鈥淯nfortunately, we do not have good evidence that implementation of the sepsis policy has led to an improvement in sepsis mortality rates,鈥 he said.
offers a different view. It showed that adhering to the treatments reduced deaths by about 5.7% among patients who received them. Medicare officials cited the study and its results in their proposal for the rule.
Rhee is unconvinced that the treatment protocols alone led to the drop.
Simpson, at the Sepsis Alliance, said there is enough evidence that the effort to follow the treatment standard resulted in improvements, and he is looking forward to more.
鈥淚t is quite clear that this works better than what was present before, which was nothing,鈥 Simpson said. If the current sepsis mortality rate could be cut 鈥渂y even 5%, we could save a lot of lives.鈥
All those involved agree that awareness is crucial, not only on the part of medical teams, but among patients, too. Crystal Waguespack, 41, a nurse in Baton Rouge, Louisiana, said she knew about sepsis but didn鈥檛 apply that to her own symptoms when she began experiencing severe pain in 2018, two weeks after an operation.
鈥淚 never checked to see if I had a fever,鈥 or noticed her increased heart rate, she said.
But she did speak up. Waguespack said the severe pain, which occurred on a weekend when her regular doctor was unavailable, led her to see a physician unfamiliar with her case who told her that the pain was normal and that she was simply anxious. So she went to the emergency department.
鈥淚 did not take no for an answer, and I think that saved my life,鈥 she said.
At the hospital, doctors found she had spinal fluid leaking and a surgery-site infection. She spent 14 days in the hospital battling sepsis, meningitis, and a heart infection.
Key takeaways from her experience: Always ask, 鈥淐ould this be sepsis?鈥 said advocates. And don鈥檛 wait.
Smith certainly wishes he had gone directly to a hospital instead of first seeing a foot specialist.
鈥淚 went to a foot doctor because my foot hurt,鈥 said Smith. 鈥淏ut a foot doctor is not an infectious disease doctor. You need to get to a place where different kinds of doctors can see you. That鈥檚 called a hospital.鈥
